complaint·September 9, 2025

The investigation revealed the following: Regarding the allegation, “Staff spoke inappropriately to resident in care.”, it is being alleged that a staff member has been observed yelling at a resident at least three (3) times. Interviews revealed the following: two (2) out of three (3) witnesses (W2-W3) and one (1) staff (S1) have denied the allegation has taken place. Resident two (R2) was not available for interview due to existing medical condition. R1 no longer resides at the facility and is unavailable for interview. Record reviews have revealed the following: Staffs one and two (S1-S2) have presented qualifications listed under Title twenty-two (22), division six (6), chapter eight (8), sections 87405, 87411 & 87412. Furthermore, S1 has completed "Person-Centered Thinking", which indicates S1 has been trained at observing a resident, rather than relying on hearsay. Based on interviews and record reviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation, “Staff do not provide adequate food service for the residents.”, it is being alleged that a resident has left the facility on a small breakfast, which resulted in this resident leaving the facility hungry. Interviews revealed the following: two (2) out of three (3) witnesses (W2-W3) and one (1) staff (S1) have denied the allegation has taken place. Resident two (R2) was not available for interview due to existing medical condition. R1 no longer resides at the facility and is unavailable for interview. Between 12:00PM and 1:00PM, LPA observed ample food storage, properly stored, along with food items that are low in sugar content which were to be provided to a resident in care. Furthermore, LPA reviewed text messages between S1 and responsible persons of a resident in care. Record reviews have revealed the following: Crossover (shift change) log have indicated staff have stayed attentive to resident(s) needs, including resident meals. All logs have noted the meals provided to R1, which indicate facility staff have made sure of R1 to have received nutritious and dietary fitting meals. Based on observation, interviews and record reviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation, “ Staff are not assisting resident with bathing needs. ”, it is being alleged that a resident had only received a shower one time per week (1x/week) instead of three times per week (3x/week), which they should be provided. Upon entrance to the facility, LPA observed the facility and did not detect any negative scent. Upon entrance to both bathrooms, LPA detected a clean scent and there was no mold/mildew present in the showers. Interviews revealed the following: two (2) out of three (3) witnesses (W2-W3) and one (1) staff (S1) have denied the allegation has taken place. Resident two (R2) was not available for interview due to existing medical condition ... Report continues, see LIC9099-C. R1 no longer resides at the facility and is unavailable for interview. Record reviews have revealed the following; Crossover (shift change) log has noted as follows: From 08/15/25 through 09/01/25, resident one (R1) has taken two (2) showers and refused one (1) shower, which indicate that R1 is offered a physical shower once (1x) every 5.66 days. Based on LPA observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff one, Janet Tyson - Adminstrator (S1), and a copy of this report has been provided.